Akcier Fizik Muayenesinde Yeni Bir Yntem AKCER ULTRASONOGRAFS

Akciğer Fizik Muayenesinde Yeni Bir Yöntem: AKCİĞER ULTRASONOGRAFİSİ Yrd. Doç. Dr. Togay EVRİN Ufuk Üniversitesi Acil Tıp Ana. Bilim Dalı

USG • Günümüzde acil servislerde kullanımı hızla artan bir tanı aracı olarak karşımıza çıkmaktadır. • Girişimsel (periferik blok , santral damar yolu , LP ) • FAST , BLUE , Yabancı Cisim , CVP, Acil Kardiyak USG , Havayolu USG , Akciğer USG……. • Lüks ------- ihtiyaç ------- olmazsa olmaz

Akciğer USG Nefes Darlığı (ASY) (acil servis) Fizik Muayene , X ray , Biyokimya USG (non-invaziv , taşınabilir , kolay kullanılabilir) BLUE , RUSH , SESAME , FALL…. . Critical care ultrasound in cardiac arrest. Technological requirements for performing the SESAME-protocol - a holistic approach. Lichtenstein D, Malbrain ML. Anaesthesiol Intensive Ther. 2015; 47(5): 471 -81. . Lung ultrasound in acute respiratory failure an introduction to the BLUE-protocol. Lichtenstein. 2009 May; 75(5): 313 -7. . BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill. Lichtenstein. Chest 2015 Jun; 147(6): 1659 -70. . Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol Lichtenstein. Chest 2008 Jul; 134(1): 11725

USG • • • Hızlı , pratik Süregelen Hasta Transport – yatak başı Çocuklar ve hamileler (radyasyon) Yoğun bakım , intraoperatif

USG

USG • • Fizik Muayene ile eş zamanlı Öksürük , travma , nefes darlığı , hemoptizi … Akciğer muayenesinin bir parçası plevra, akciğerler, göğüs duvarı , mediasten ve diyafram görsel olarak değerlendirme imkanı sunduğu için öne çıkmaktadır.

Akciğer USG • Akciğer iç organlarımız arasında en çok hacime sahip organdır; yüzey alanı 1500 cm² olan bu organı incelerken probu nereye koyalım? • “Steteskopu nereye koyuyorsak probu da oraya koyabiliriz”(sarı alan ve yeşil alan) • Kritik hasta bakısında bize zaman çok daha değerli olduğu için BLUE , PLAPS protokolleri önerilse de.

USG Cihazları ve Probları • Her türlü usg cihazı ile akciğer usg’si yapılabilir. • Taşınabilir , hafif ve küçük • M mode • Power Doppler • Lineer Prob • Konveks Probda

USG Teknik • Steteskopu nereye koyuyorsak probu da oraya koyabiliriz

USG Teknik bat-sign (the wings of the bat) Üst ve alt kot

USG Teknik Eight-zone scanning scheme of the antero-lateral chest(PS: parasternal, AA: Anterior axillary, PA: Posterior axillary ASY ‘ de , 2 bölgenin hızlı usg bakısı intersisyel akciğer hastalığı ve kardiyojenik akut pulmoner ödemi dışlamada yeterlidir.

USG Teknik • • her iki costaphrenic sinus Konveks prob Subdiyafragmatik organlar (kc ve dalak) en ideali oturur pozisyonda , axiller hattan

Artefakt ve Normal Bulgular Plevra 0. 2 to 0. 4 mm , hiper ekoik çizgi 0, 5 cm kot altında • lung sliding ( amplitude of the lung sliding is minimal at the apices and maximal at the bases) • The sea-shore sign (M mode) • Horizontal lines • B lines

Artefakt ve Normal Bulgular

Plevral Efüzyon • USG hem akciğer oskültasyonu hem de x raye göre plevral effüzyonu tanısal doğrulamada daha etkin. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ: Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in acute respiratorydistress syndrome. Anesthesiology 100, 9– 15 (2004) Xray Ortastatik pozisyonda effüzyon en az 200 m. L supin pozisyonda duyarlılık daha da azalır. USG 20 ml sıvıyı değerlendirebilir Blackmore CC, Black WC, Dallas RV, Crow HC. Pleural fluid volume estimation: a chest radiograph prediction rule. Acad Radiol. 1996; 3(2): 103 -9. Lichtenstein D, Goldstein I, Mourgeon E, Cluzel P, Grenier P, Rouby JJ: Comparative diagnostic performances of auscultation, chest radiography and lung ultrasonography in acute respiratorydistress syndrome. Anesthesiology 100, 9– 15 (2004)

Plevral Efüzyon • Efüzyonun karakteristiğine göre transuda ve eksüda ayrımı yapılabilir. • Anekoik (siyah) • Kompleks septasız (siyah içinde beyaz ekoik fibrin) • kompleks septalı (siyah içinde beya septalar),

Plevral Efüzyon

Plevral Efüzyon Ampiyem bal peteği görünümü

Pnömotoraks stratosphere sign Lung point Lung sliding azalması

Pnömotoraks • Lung point pnömotoraks için %100 tanı koydurucu • lung sliding jet or high-frequency ventilation, masif atelektazi , plevral fibrosis, frenik sinir paralizisi, cardiopulmonary arrest, apne

Pnömotoraks

Pnömoni • USG sensitivite (94%) and spesifisite(96%) Miguel A Chavez, Navid Shams, Laura E Ellington 1, et al, Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis Respiratory Research 2014, 15: 50

Pnömoni • • • Hipoekoik alanlar(fluid bronkogram) Düzensiz , çıkıntılı akciğer sınırları Hava bronkogram Pleural effusion Vascular akım konsolide akciğer alanında ( color or power Doppler imaging) • Akciğeride hepatizasyon bulgusu Michael Blaivas Lung Ultrasound in Evaluation of Pneumonia J Ultrasound Med 2012; 31: 823– 826

Pnömoni White arrow shows air bronchograms in tissuelike sonographic pattern of lung a the presence of consolidation with evidence of air bronchograms, b Air bronchograms are seen in the infected area as branching echogenic structures

Pnömoni a Fluid bronchograms, which are frequently observed in post obstructive pneumonia, appear as anechoic tubular structures with hyperechoic walls without any color Doppler signal, b LUS reveals air and fluid bronchograms within the affected area

Pnömoni Fluid bronchograms, which are frequently observed in post obstructive pneumonia, appear as anechoic tubular structures with hyperechoic walls

Intersisyel Sendrom ve Akut Pulmoner Ödem LUNG ROCKETS • sensitivite pulmonary ödem 100% and spesificite 92% • sensitivite ve spesifite 93% Intersisyel Sendrom LUNG ROCKETS Angelika Reissig , Roberto Copetti Lung Ultrasound in Community-Acquired Pneumonia and in Interstitial Lung Diseases Respiration 2014; 87: 179– 189

Lung Rockets Lung rockets , horizontal A lines yok

Göğüs Duvarı • Kot ve sternum fraktürleri (hematom ya da deplase) • Pnömotoraks ve hemotoraks (komplike) • Diyafram (travmaya bağlı rüptür , paralizi KOAH sınıflandırması)

Göğüs Duvarı

Göğüs Duvarı ( Rib fracture) Diagnostic US in the longitudinal plane of a rib consistent with a fracture and surrounding hematoma (asterisk) displacing the overlying pectoralis minor muscle (pm) and a portion of the pectoralis major muscle (PM

Sınırlar • • Obezite Kişi bağımlı Amfizem Sol kostofrenik sinüs

Sonuç • • Güvenilir , kolay , ucuz tanısal bir araç Radyasyon Transport Yeni USG cihazları akciğer muayenesi

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